Provider Demographics
NPI:1902407760
Name:ROMERO, THALIA MERCEDES
Entity Type:Individual
Prefix:
First Name:THALIA
Middle Name:MERCEDES
Last Name:ROMERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 MALABAR RD SW APT 102
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3302
Mailing Address - Country:US
Mailing Address - Phone:321-423-3704
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD STE 180
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7277
Practice Address - Country:US
Practice Address - Phone:321-255-6627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17968224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant